This form is for A.P.S.
For other requests, please click
Please provide the following agent information:
Records pertain to:
Please identify location of records:
PLEASE FOLLOW THESE INSTRUCTIONS WHEN
1. Be sure to send or fax us applicant's consent to release medical
2. Full name of the doctor/hospital, address and phone number.
3. If patient is a member of Kaiser or FHP, be sure to include their
4. If patient has been seen by a doctor through military service, be sure
to include social security number.
Please enter important notes or special instructions here: